Professional Documents
Culture Documents
2016 Updated ACLS Handouts PDF
2016 Updated ACLS Handouts PDF
, FACOEP
ACLS ECG Rhythms
PCOM-EM
1
S.A. Pulley, D.O., FACOEP
ACLS ECG Rhythms
PCOM-EM
VII. Tachycardias
A. SVT (Narrow Complex)
1. Sinus Tachycardia (See above for ST)
a. Normal P-R
2. Multifocal Atrial Tachycardia
a. Ps variably different
3. Atrial Tachycardia
a. Ps abnormal but non-variable
b. Or too fast for Sinus Tachycardia
4. Paroxysmal-Start/Stop on own
2
S.A. Pulley, D.O., FACOEP
ACLS ECG Rhythms
PCOM-EM
c. Unstable
i. SBP<90 (or so), Change in responsiveness, Crushing CP, CHF
d. Unstable Electricity Requires Electricity to fix it
e. Stable Electricity Gets Medical Therapy
B. Wide Complex Tachycardia (Fast, Wide, No P Waves
1. SVT with Aberrancy
a. Preexisting Bundle Branch Block
2. Ventricular Tachycardia
B. PJC-Junctional ( No P waves)
C. PVC-Ventricular
1. Unifocal
2. Multifocal
3. Couplets
IX. No P Waves
A. Junctional Rhythm
1. Junctional Escape (40-60 bpm)
2. Accelerated Junctional (>60 bpm)
B. Idioventricular
1. Ventricular Escape (20-40 bpm)
2. Idioventricular (>40 bpm)
3
S.A. Pulley, D.O., FACOEP
ACLS ECG Rhythms
PCOM-EM
1
2 3
6 7
8 9
10
11
12: A B C
D
4
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
ACLS Pharmacology
I. Snap Shot of Instability
A. ABCDEs
B. Vital Signs
i. Heart Rate, Respiratory Rate, Blood Pressure
ii. Pulse Oximetry, Blood Sugar
iii. Temperature
C. Mental Status
i. Confusion
ii. Disorientation
D. Symptoms
i. Chest Pain
ii. Dyspnea
iii. Lightheadedness
E. Physical Signs
i. Respiratory Distress
ii. Pallor
iii. Diaphoresis
II. Initial Management
A. Rapid Assessment
i. ABCDEs
ii. Mental Status
iii. Gross Appearance
iv. Pulse/HR/RR
B. 12 Lead ECG
C. Oxygen (O2) if Pulse Ox<94%
D. Cardiac/Pressure/Pulse Ox Monitor
E. Treatment based on findings
F. Pay Attention
i. Time => Brain Cells
ii. Time => Resistance to Defibrillation
iii. Time => Muscle
III. Drug Class Recommendations
A. Class I
i. Always indicated
ii. Solid proof of utility
B. Class IIa
i. Probably helpful
ii. Most data support use
C. Class IIb
i. Possibly helpful
ii. Some supportive data
iii. Not harmful
D. Class Indeterminate
i. Insufficient scientific evidence at this time
E. Class III-Contraindicated/Harmful
1
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
IV. PAY ATTENTION
A. Time is Critical
i. Time=>Brain Cells
ii. Time=>Resistance to Defibrillation
iii. Time=>Cardiac Muscle
V. Do drugs make a difference?
A. Not really
VI. What makes a difference?
A. Optimal compressions
B. Avoid hyperventilation
C. Early defibrillation
VII. Dead Rhythms (Rhythms without a pulse) Therapy
A. Treatment
i. Oxygen
ii. Epinephrine
iii. (Lidocaine/Amiodarone)
iv. Defibrillation
v. Magnesium Sulfate
B. Dead Box (Algorithm box)
i. All dead rhythms (no pulse) have common elements of treatment
ii. All get/continue AAA-CAB/CPR
iii. All get an IV or IO
iv. All get Epinephrine 1 mg IV (1:10,000)
v. All get intubated/advanced airway when convenient
CAB-D/CPR
vi. Elements added at beginning or end
C. Oxygen
i. Always administer 100% FiO2 in Arrest states I V /I O
ii. Cardio-Respiratory distress
iii. Class: I
iv. Contraindications-COPD
Epi 1 mg IV
1. Never withhold Oxygen in hypoxic states (Vasopressin 40 u IV)
2. Monitor ventilation (pCO2) and assist prn
3. Intubate if necessary
v. However, in ischemic states once patient stabilized Intubate
1. Back off on FIO2 to keep pulse ox>94%<100% (When Convenient)
D. Ventilation Technique
i. No advanced airway: 30:2 (Compressions:Ventilations)
ii. Yes advanced airway: 1 breath Q 6 seconds
1. Same if Respiratory Arrest only
2. Same for Children <8 y/o except:
a. 15:2 if two rescuers no advanced airway
iii. Normal tidal volume 6 ml/kg
iv. Code Volume:
1. No O2: 10 ml/kg over 1 second
2. Yes O2: 6-7 ml/kg over 1 second
v. Goal is PaCO2/ETCO2 of 35-40
vi. Avoid Hyperventilation=>Respiratory alkalosis and decreased cerebral perfusion
E. Epinephrine
i. Potent Vasoconstrictor
ii. Beta1, Beta2, & Alpha1, Alpha2 Stimulation
iii. Administration IV/IO, (ETT if no IV/IO
iv. Dose
1. IV: 1 mg q3 5 min
a. ETT: 2 2.5x IV dose=>Intraosseous recommended!
v. Indications-Class I
vi. V-Fib, Unstable V-Tach, Asystole, PEA
vii. (Also, IM/SQ for Anaphylaxis or Status Asthmaticus)
1. 0.3 mg (0.3 ml of 1:1K)
2
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
viii. Contraindications / Cautions
1. Stable Vital Signs
2. Caution in elderly
F. No IV?
i. Preference is IV or IO (Intraosseous)
ii. However, drugs that can be given via Endotracheal Tube (ETT)
iii. True ACLS Drugs (A-L-E)
1. Atropine
2. Lidocaine
3. Epinephrine
iv. (N-A-V-E-L)
1. Add Narcan and Vasopressin
G. Asystole-Check that leads are attached and check in more than one lead
i. Recommend the same for VF
H. PEA (Pulseless Electrical Activity)-If bradycardic could consider transcutaneous pacing
VIII. Ts and Hs
A. Anytime the patient is not doing well
i. Do primary survey, ABCDE
ii. Check 6 vital signs (BP-HR-RR-T-PO-BS)
B. Consider the Ts and Hs (order reversed on purpose) (5 each)
i. Tension Pneumo, Tamponade, Thrombosis-Pulmonary, Thrombosis-Coronary,
Toxins/Tablets
ii. Hypoxia, Hypovolemia, Hyperacidemia, Hyperelectrolytemia, Hypothermia
C. PALS has 6 each adding Hypoglycemia and Trauma (for hemorrhage)
IX. VF/Pulseless VT
A. Time => Resistance to Defibrillation
B. Quick Look for and immediate Defibrillation if appropriate
C. SHOCK at maximum for device
i. 360 J Monophasic or 120-200 (up to 360) J Biphasic depending on the machine.
ii. Time to shock is critical
iii. Try to defibrillate as close to time 0 as possible
D. Dead Box Therapy
i. CAB-D/CPR
ii. IV/IO
iii. Epinephrine 1mg IV
iv. Intubate/advanced airway when ready/convenient
E. 2 minute blocks for code
i. CAB/CPR to Circulate drug for 2 minutes
ii. Drug at beginning of the block
1. (Every other 2 minute block is Epi step)
iii. Reevaluate-TRIAD
1. Rhythm-if potentially perfusing check:
2 Minutes 2. Pulse-to see if it is perfusing:
3. BP-to see how well it is perfusing
4. If awake, dont forget to ask how they are
iv. Shock-if shockable rhythm
v. DO NOT PAUSE TO CHECK RHYTHM IMMEDIATELY AFTERWARDS
1. Wait for 2 minute mark due to myocardial stunning
vi. Go back to i. to start next block and give next drug (if indicated)
F. Amiodarone
i. Anti-Dysrhythmic
ii. Action:
1. Works @ AV Node, Bundles, & Ventricles
iii. Administration: IV
3
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
iv. Dosage:
1. VF / Unstable VT: 300 mg IVP
a. Repeat after 4 minutes once at (150 mg IVP)
2. Stable VT/SVT: 150 mg over 10 minutes
3. Then administer @ 1 mg/min X 6 hrs
4. Then @ 0.5 mg/min X 18 hrs
v. Indications
1. VF, Stable / Unstable VT & SVT
vi. Contraindications / Cautions
1. Caution in hypotension, Hypersensitivity
G. Lidocaine
i. Class: IIb
ii. Anti-Dysrhythmic
iii. Action: works @ Bundles & Ventricles
iv. Dose:
1. Bolus: 11.5 mg/Kg IVP Max Dose 3 mg/Kg
2. Repeat: 1/2 of bolus (0.5-0.75 mg/Kg)
3. Infusion: 1 4 mg / min
v. Indications
1. VF, VT
vi. Contraindications / Cautions
1. Hypotension, Hypersensitivity
H. Magnesium Sulfate
i. Action: Cardiac membrane stabilization
ii. Administration: IV
iii. Dose
1. 1 2 grams IV over 5 60 min in 50 100 cc
iv. Indications
1. Torsades de Pointe => Class I
2. Hypomagnesemia, Status Asthmaticus
v. Contraindications / Cautions
1. Not recommended routinely in cardiac arrest
X. Too Fast (Tachycardic) Therapy
A. Anti-dysrhythmics
i. Lidocaine, Amiodarone, Magnesium (done above)
ii. Procainamide
1. Anti-dysrhythmic
2. Action: AV Node, Bundles & Ventricles
3. Dose
a. Code: 50 mg/min
i. 1 gm in 100 cc @ 300 cc/h = 50 mg/min
b. Therapeutic: 20 30 mg/min
i. 1 gm in 100 cc @ 150 cc/hr = 27 mg/min
c. Maximum 15 mg/kg (~1 gm)
4. Indications
a. Atrial & Ventricular Dysrhythmias
5. Contraindications / Cautions
a. Hypotension
b. Do not use with Amiodarone
c. Avoid in Torsades
6. Reasons to Stop
a. Hypotension
b. QRS width > 50% of baseline
c. Reach maximum dose of 1 gm (15 mg/kg)
d. Dysrhythmia suppression
4
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
B. Generally treatment of SVT is:
i. Stable SVT: Vagal Maneuvers then Adenosine then Rate Control with Beta or
Calcium channel blockers
ii. Unstable SVT (See I below): Synchronized Cardioversion
iii. Stable Tachycardia
1. SBP>90
2. Normal mentation
3. No chest pain
4. Clear lungs/No dyspnea
C. 1st Vagal Maneuvers-Hands on-Remember you are an Osteopathic Physician!
i. Eyeballs-Ocular Pressure
1. ***Caution in elderly
ii. Face-Surprise ice water immersion
iii. Neck-Carotid sinus massage
1. ***Caution in elderly
iv. Belly-Valsalva
v. Butt-Anal Massage
vi. (Not in ACLS book: V-Spread)
D. Adenosine
i. Action: AV node blockade
ii. Half-Life: < 10 seconds
iii. Administration: IV Rapid Push through at least proximal 18 ga.
1. With immediate slam IVP NSS bolus 10-20 ml
2. And raise arm to enhance return
iv. Dose: 6 mg => 12 mg => 12 mg?
v. Indications: SVT, PSVT
vi. Contraindications / Cautions
1. May slow Atrial Fibrillation only
2. Dont use diagnostically in Wide Complex Tachycardia
3. Effectiveness with Theophylline, Dipyridamole, Carbamazepine
4. May cause bronchospasm
vii. WARN the patient as it transiently stops the heart (Dont tell the patient THAT!)
E. Verapamil
i. Action: Calcium Channel Blocker, AV Node Blockade
ii. Administration: IV
iii. Dose
1. 2.5 5 mg IV / 1 minute (0.075 0.15 mg / Kg)
2. Re-dose 5-10 mg in 15-30 mg
iv. Indications
1. Rate control of Narrow Complex Tachycardia
v. Contraindications / Cautions
1. Wide Complex Tachycardia (re-entry)
2. Hypotension (may result in hypotension)
3. Calcium IV may be given if adverse effects
F. Diltiazem
i. Action: Calcium Channel Blocker, AV Node Blockade
ii. Administration: IV, PO
iii. Dose
1. 1st Dose: 0.25 mg/Kg IV (5 10 mg)
2. 2nd Dose: 0.35 mg/Kg IV (10 15 mg)
3. Infusion: 5 15 mg/hr
iv. Indications
1. Rapid Atrial Fibrillation, other SVT's
v. Contraindications / Cautions
1. Hypotension
2. Wide Complex Tachycardia
vi. May administer Calcium IV to reverse effects
5
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
G. Metoprolol/Atenolol and Labetolol
i. Action: Beta Blocker, AV Node Blockade
ii. Dose
1. Labetalol: 10 20 mg IV over 1 2 min
a. Double with each subsequent dose q10 min
b. Infusion: 2 8 mg / min
2. Metoprolol: 5 mg IV over 2 5 min q 5 min (x 3 for ACS)
a. PO Dose given after IV loading
iii. Indications
1. Hypertensive Emergency
2. Heart Rate Control (esp. AMI) or SVT
iv. Contraindications / Cautions
1. Hypotension, Bradycardia
H. Esmolol
i. Titratable Beta Blocker
ii. Short half life
iii. Little hypotension or bronchospasm
iv. 250-500 mcg/kg IVB over 1 minute
v. Then 25-50 mcg/kg/min
vi. Re-bolus q 5 min PRN
vii. Increase in 50 mcg/kg/min steps to max of 200 mcg/kg/min
I. Sotalol
i. Action:
1. Blockade at AV Node, Bundles & Ventricles
ii. Dose
1. IV: 1 1.5 mg/Kg @ 10 mg/min
2. PO: 40 80 mg PO BID
iii. Indications
1. Ventricular & Supraventricular Dysrhythmias
iv. Contraindications / Cautions
1. Bradycardia
2. Hypotension
3. Pro-Dysrhythmic (Torsades)-So not used much
v. Limited by Slow infusion rate
J. If you use Calcium Channel or Beta Blocker be prepared to synchronized cardiovert
i. You can make them and Unstable Tachycardia mostly through hypotension
ii. Because they all have antihypertensive properties
iii. Or, if they have a bypass tract tachycardia (e.g. WPW, LGL, etc.)
1. Blocking the AV node pushes all the impulses to the bypass tract
2. Which causes the HR to zoom up, and the BP crash
K. Synchronized Cardioversion for Unstable Tachycardias
i. When presented with a tachycardia, decision point as to whether stable or
unstable
ii. Unstable Electricity requires Electricity to fix it
iii. SVT or VT
iv. Unstable-Only need one of the following to be unstable
1. Hypotension (SBP<90)
2. Significant change in mental status
3. Cardiogenic chest pain
4. Dyspnea from pulmonary edema/CHF
v. Joules-Monophasic or Biphasic
1. 100 J (If A-Flutter 50 J)
2. 200 J
3. 300 J
4. 360 J
6
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
XI. Shock (Hypotension) Therapy
A. Oxygen (Above)
B. Normal Saline Solution
i. Crystalloid
ii. Preferred resuscitation solution
iii. First line treatment of hypotension
iv. 250 ml-1000 ml fluid bolus IV
1. Amount driven by clinical situation
v. Caution (Doesnt mean dont give it)
1. CHF (or History of CHF), Elderly
2. Renal Failure
C. Dopamine
i. Action:
1. Dopaminergic (Renal Artery Dilatation)
2. Beta (Inotropic & chronotropic heart stimulation)
3. Alpha (Peripheral arterial constrictor)
ii. Dose
1. Dopaminergic: 3 5 ug/kg/min
2. Beta: 5 10 ug/kg/min
3. Alpha: 10 20 ug/kg/min (Shock Dose)
iii. Indications: Hypotension
D. Dobutamine
i. Action: Inotropic beta stimulation, increases cardiac contractility
ii. Dose: 5 20 ug/kg/min
iii. Indications: Cardiogenic Shock
iv. Adverse Effects: Hypotension due to arterial dilatation
v. Do not administer unless SBP > 90 mmHg
E. Norepinephrine
i. Action: Pure alpha stimulation, potent arterial constrictor
ii. Dose: 4 8 ug/min
iii. Indications: Refractory Hypotension
iv. Very good for poor vascular tone shock such as neurologic or septic
F. Epinephrine (Above)
XII. Too Slow (Bradycardia) Therapy
A. Atropine
i. Action: AV Node stimulation
ii. Dose: IV
1. 0.02 mg/Kg IV (minimum dose = 0.1 mg)
2. Bradycardia Dose: 0.5 mg IV (Dont want to overshoot)
a. No longer indicated for Asystole
iii. Indications
1. Sinus Bradycardia with significant HypoTN (Class I)
2. Other Symptomatic Bradycardia (Class IIb)
3. Contraindications / Cautions
a. Use caution in Mobitz II and 3rd AV Block
b. May increase degree of block
B. Dopamine-Beta Property (Above)
C. Dobutamine-Beta Property(Above)
D. Epinephrine-Beta Property (Above)
E. Isoproteronol-Pure Beta-Just mentioning, rarely utilized
i. 2-10 mcg/minute
ii. 2 mg in 250 ml starting at 15 ml/hr
iii. Sympathomimetic with pure beta
iv. Potent inotropic and chronotropic effects
7
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
F. Symptoms
i. Mild=>Perhaps no treatment, just monitoring
ii. Moderate=>Atropine and if it doesn't work a Beta drug
iii. Severe "Unstable"-SBP<90, Confusion, CP, CHF
1. Unstable Electricity Requires Electricity=>Pacing
G. Pacemaker-
i. Transcutaneous easiest to place
ii. Any symptomatic bradycardic rhythm
1. Especially if with severe symptoms or perfusion issues
iii. Absolute consideration for Mobitz 2 and 3rd degree AVB
iv. Downside is that TCP is uncomfortable
XIII. Too Wet (Fluid Overload) Therapy
A. Oxygen (Above)
B. Nitroglycerin
i. Coronary Artery Vasodilator
1. Decreases preload first, Then afterload at higher doses
ii. Dosage:
1. SL: 300400ug (0.30.4mg) q5 min
2. IV: 1020 ug/min & titrate by 10ug q 5 min
3. TC: - 2 inch paste to chest wall
iii. Indications
1. Ischemic Cardiac Chest Pain, CHF
2. Hypertension (Including Hypertensive Emergency)
iv. Contraindications / Cautions
1. Hypotension (SBP < 90)
2. Viagra/Cialis/Levitra
3. Revatio/Adcirca (used for pulmonary hypertension)
C. Positive Pressure Airway-CPAP, BiPAP, or Ventilator
D. Furosemide
i. Loop Diuretic
ii. Dose:
1. 0.5 - 1 mg/kg IV (~40 mg)
2. Avoid over diuresing
iii. Indications:
1. Pulmonary Edema, Hypertensive Crisis
2. Increased ICP
iv. Cautions:
1. Low BP
2. Hypovolemia
3. Electrolyte lows
E. Dopamine-Beta Property (Above)
F. Dobutamine-Beta Property (Above)
XIV. Too High (Pressure) Therapy
A. Nitroglycerin-Afterload reduction (Above)
B. Nitroprusside-Just mentioning, rarely utilized
i. Potent vasodilator
ii. Indications:
1. High SVR cardiogenic shock, pulmonary edema, acute MVR or AVR
2. Reduces afterload
iii. Indicated for severe hypertension
iv. Mix 50-100 mg in 250 D5W
1. Range 5-10 mcg/kg/min
2. Begin 0.1 mcg/kg/min
3. Light sensitive: Cover the IV bag
C. Beta Blockers-Afterload reduction (Metoprolol/Atenolol, Labetolol Above)
8
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
XV. Acute Coronary Drugs- (Covered in the ACS Lecture)
A. Oxygen (Above)
B. Nitroglycerin (Above)
C. Aspirin
D. Heparin/Lovenox
E. Beta Blockers (Above)
F. Opiates
G. Thrombolytics
XVI. Miscellaneous Drug
A. Calcium Chloride
i. Indications:
1. Hyperkalemia, Hypocalcemia
2. Antagonize Ca+ Channel Blockers
ii. Dose:
1. 8 - 16 mg/kg (5 - 10 ml) IV
iii. Precautions:
1. Do not use routinely in cardiac arrest
2. Do not mix with Sodium Bicarbonate
B. Sodium Bicarbonate
i. Action: Uncertain
ii. Dose
1. Initial: 1 meq/Kg IV Bolus
2. Repeat: 0.5 meq/Kg q 10 min
iii. Indications
1. Class I
a. TCA or Phenobarbital Overdose
b. Hyperkalemia
c. Known pre-existent Metabolic Acidosis
2. Class II b =>Protracted Code
iv. Contraindications / Cautions
1. Avoid admixture or infiltration with Calcium or Epinephrine
2. Use only after other Class I / Class II drugs
9
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
1
S.A. Pulley, D.O., FACOEP
ACLS Pharmacology
PCOM-EM
2
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
1
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
2
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
3
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
XV. CT Scan
A. Fast, widely available, cheaper than MRI
B. Detects ICH/SDH/EDH about 100% of the time
C. Does not show CVA
D. Misses about 3-6% of SAH
XVI. MRI
A. Can show tissue that is dead and that at risk (penumbra)
B. MRA shows the circulation
C. Takes longer, not readily available, more expensive
XVII. Hemorrhagic CVA
A. CT (+) For Bleed
B. ICH 10%, SAH 6% of CVAs
C. Requires Neurosurgical Consultation and Neuro ICU admission
4
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
Stroke Distributions
Vascular Territories
XVIII. Anterior Cerebral Artery-2%
A. Contralateral paresis, Legs>Arms
B. Sensory deficit in the same distribution
C. Gait disturbance due to weakness, not cerebellar balance dysfunction
XIX. Middle Cerebral Artery-90%
A. Contralateral paralysis, Face/Arms>Legs
B. Sensory deficit in the same distribution
C. Aphasia (if dominant hemisphere)
D. Hemineglect (if nondominant hemisphere)
E. Homonymous hemianopsia
1. Eyes look towards the side of the stroke
2. Vision preserved on the side of the stroke
F. Right-handed=>Left hemisphere dominant=>Left MCA CVA
1. Right hemiparesis & sensory deficit
2. Aphasia
3. Right homonymous hemianopsia-(Looks to right)
G. Right-handed=>Left hemisphere dominant=>Right MCA CVA
1. Left hemiparesis & sensory deficit
2. Left hemineglect
3. Left homonymous hemianopsia-(Looks to left)
H. Reverse for opposite handedness and dominance
I. Left-handed=>Right hemisphere dominant=>Right MCA CVA
1. Left hemiparesis & sensory deficit
2. Aphasia
3. Left homonymous hemianopsia-(Looks to left)
J. Left-handed=>Right hemisphere dominant=>Left MCA CVA
1. Right hemiparesis & sensory deficit
` 2. Right hemineglect
3.Right homonymous hemianopsia-(Looks to right)
XX. Posterior Cerebral Artery-5%
A. Supplies occipital cortex=>one of the following:
1. Homonymous hemianopsia on contralateral side
2. Right artery looks left, Left artery looks right
3. Visual agnosia-Can't recognize objects
4. Cortical blindness
5. Plus:
a. Confusion
b. Paresthesias
c. Dizziness
d. Nausea
e. Memory loss
f. Language dysfunction
g. Minimal motor involvement in the form of a tremor
5
S.A. Pulley, D.O., FACOEP
Acute Brain Syndrome
PCOM-EM
6
S.A. Pulley, D.O., FACOEP
Acute Coronary Syndrome
PCOM-EM
1
S.A. Pulley, D.O., FACOEP
Acute Coronary Syndrome
PCOM-EM
C. ECG Regions
1. II, III, F: Inferior wall
2. V1 - V2: Interventricular septum
3. V3 -V4: Anterior wall
4. I, L: High lateral wall
5. V5 - V6: Low lateral wall
6. R V3 - RV4: Right Ventricle
7. Mirror V1 - V2 or V9: Posterior Wall
IX. Differential Diagnosis
A. Acute Coronary Syndrome***(Short term life threat)
B. Thoracic Aneurysm Dissection***(Short term life threat)
C. Pneumothorax***(Short term life threat if Tension)
D. Pulmonary Embolism***(Short term life threat)
E. Booerhaves***(Short term life threat)
F. Trauma
G. Pleurisy/Pneumonia
H. Pericarditis
I. GERD/Esophagitis
X. Risk Factors for AMI
A. Not Modifiable
1. Prior disease (MI, bypass, angioplasty), Family history, Age/Sex
B. Modifiable
1. Sedentary, Obesity, HTN, Smoking, Hyperlipidemia, DM
C. Other Modifiable
1. Stress, Poor nutrition, Excessive alcohol, Cocaine, Methamphetamine
XI. Cardiogenic Chest Pain-Chest Discomfort
A. Pressure
B. Tightness
C. Heaviness
D. Squeezing
E. Bricks or elephant sitting on chest
F. Any discomfort from umbilicus to upper teeth, front or back, in the right patient, can be
considered cardiac related
G. The older the patient is, females, or the longer that the patient has had diabetes, the less
typical the symptoms tend to be
XII. Cardiogenic Symptoms
A. Chest discomfort
B. Levine sign
C. Shortness of breath
D. Diaphoresis
E. Nausea/vomiting
F. Radiation
XIII. Public Awareness
A. 92% recognize chest pain as a symptoms of heart attack
B. Only 27% were aware of all the major symptoms and knew to call 9-1-1
C. With about 47% of people dying outside the hospital from cardiac arrest, it appears that most
do not heed the warning symptoms of heart attack
XIV. Atypical Symptoms
A. Any discomfort from umbilicus to upper teeth, front or back, in the right patient, can be
considered cardiac related
B. The older the patient is, females, or the longer that the patient has had diabetes, the less
typical the symptoms tend to be
XV. Decision Process
A. More likely to have
1. Risk factors
2. Suspicious story (Symptoms) which is the most important factor
2
S.A. Pulley, D.O., FACOEP
Acute Coronary Syndrome
PCOM-EM